Session SOAP Note

Question 1

S - Subjective

Answer 1

• What the patient reports. Their own perceptions.
• Addresses:
  – What changes the patient perceives in impairments, activity and/or participation limitations
  – Response to previous interventions
• Try to be specific and avoid “judging” patient’s mood.
  – Ex: patient is frustrated with pain
• May need to use quotations of patient exact words
  – Ex: patient states she “ is frustrated that she continues to have pain with walking”

Can directly quote patients here

Question 2

O - Objective

Answer 2

Document any specific measurements taken
– usually include the asterik signs we have discussed
– Qualitative and quanitative data.

Document intervention performed on that day (more specific than initial note)
– Needs to be specific interventions including location, intensity, duration, sets/reps. Sometime in chart form.
Include specific cues or skills during inervention that display care
– Include any change in HEP

Question 3

A - Assessment

Answer 3

How did patient respond to intervention? Reassess asterisk signs. “Within session changes?”

How is patient progressing to the goals established at initial evaluation. “Between session changes?”

Within and between session changes

Pretty short

Question 4

P - Plan

Answer 4

• How will intervention change next treatment based on how patient responded in the session.
• Anticipate how next intervention will be adjusted if patient feels better or worse. In other words, how would you increase vigor of treatment or decrease the vigor of treatment